Insurance and Service Authorization Form
​Please fill out the form below indicating your insurance preference. After you have completed a page, please hit "Next" to go to the following page. Once completed, select "Submit" and your form will be forwarded to the appropriate staff member.

​If you prefer to fill out your insurance authorization on a physical form, we invite you to download the Insurance and Service Authorization Form, complete and fax it to us at (612) 706-5555. Please print completed documents for your personal records. You may also fill out the form on your computer and upload a completed PDF version in the upload form box below. 

If you have questions or need more information, please contact us at (612) 789-1236 or email rehabclinic@actg.org.
Data Privacy
We invite you to visit our Privacy Practices page to review our policies regarding the security of your information. This page describes how medical information about you may be used and disclosed and how you can get access to this information.

Your Personal Health Information (PHI) may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care.

​Example: If another physician referred you to us, we may contact that physician to discuss your care. Likewise, if we refer you to another physician, we may contact that physician to discuss your care or they may contact us.
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If you have questions or need more information, please contact us by calling (612) 789-1236 or email rehabclinic@actg.org.